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Waste Tire SL. ,ey & Inspection Report inspection Report Number i <br /> CalRecycle state of California 11 - 1210 319 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ _BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � Inspection Type(Fill one) <br /> Site Suffix: O Routine Q Re-inspection Q Referral Q Observation <br /> Localc If Referral,choose referral type(Fill one) <br /> Identifier: 5CL n TO <br /> V ./\ V,^� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 1500 �a Q� <br /> P -53Inspection Date <br /> U0`��(-0 \ �� Time In Time Out <br /> Business Rep Title &AM 0 AM <br /> 1 © • 2 d © PM lJ J Q PM <br /> co Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> b Active 0 Passenger Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> ��� Latitude Q Hauler Q Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - Q Planned O OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M09 <br /> b S I 3 <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> r <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> — z <br /> Comments ` A 1S v� � N <br /> � kNn IZ <br /> Inspection Form Included: Q (� <br /> Comments Included: � - <br /> Business Rep's Signature Phone Number �Inspeor'�sgnature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />